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• Screen for papilledema if headache, nausea, and vomiting u TIP occurs aseudotumor cerebri occurs P more often with co-adminis- • Recent reports of serious psychiatric events possibly related tration of a tetracycline to isotretinoin have drawn considerable attention. A large population based study with control groups failed to show an increased risk of depression, suicide attempt and suicide among isotretinoin treated patients14 Hormonal Therapies • May be an important component of acne treatment in the female patient, especially for adult women with a predominance of acne at the lower face • Most common endocrinopathy associated with acne is polycystic ovary syndrome (PCOS), characterized by acne, obesity, hirsutism, amenorrhea and glucose intolerance • Congenital adrenal hyperplasia (CAH) is also associated with acne • Although rare, very high levels of DHEA-S may suggest an adrenal androgen-secreting tumor • A patient whose acne fails to respond to conventional therapy, whose acne flares cyclically, with hirsutism, alopecia or irregular menses warrants an endocrine work-up, including free and total testosterone, LH, FSH, and DHEA-S • Benefit from hormonally-based therapies, such as oral contraceptives (OCPs) • Usually ethinyl estradiol. OCP’s lead to a decrease in free testosterone levels by increasing the adrenal production of sex hormone binding globulin (SHBG) • Spironolactone, commonly dosed between 50 to 200 mg/day → blocks androgen receptors and adrenal androgen synthesis. Side effects include menstrual irregularities, breast tenderness, and intestinal symptoms, which can be mitigated by concomitant OCP use. Hyperkalemia is more likely in the setting of renal failure. Spironolactone is not FDA- approved for the treatment of acne. It is pregnancy category X4.2 Rosacea • Papules and papulopustules in central region of face against a vivid background of telangiectases. Later, diffuse hyperplasia of connective tissue with enlarged sebaceous glands • Localized to nose, cheeks, chin, forehead, glabella; less commonly affected areas include the retroauricular, V-shaped chest area, neck, back, scalp • Flushing and blushing evoked by UV, heat, cold, chemical irritation, strong emotions, alcoholic beverages, hot drinks, and spicesVariants of Rosacea Persistent Edema of Rosacea (Rosacea Lymphedema or Morbihan’s Disease) • Hard, nonpitting edema • Often misdiagnosed as cellulitis Ophthalmic Rosacea • Blepharitis, conjunctivitis, iritis, keratitis (inflammation of cornea) • The treatment of choice for ocular rosacea is oral antibiotics General Dermatology 79

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UV Phototherapy • UVB useful adjunct to treatment of chronic recalcitrant AD • High intensity UVA can be fast-acting and effective with acute exacerbations of AD Systemic Cyclosporine or Tacrolimus • Oral cyclosporine or tacrolimus can help severe AD that is refractory to topical steroids • Discontinuation of treatment may result in rapid relapse of skin disease Probiotics • The utility of probiotics in primary prevention of atopic dermatitis has been studied • Lactobacillus GG cultures were given to pregnant women with a history of atopy to assess the effect of potentially beneficial gut flora on the prevention of atopic disease in their children • Frequency of atopic dermatitis in the probiotic group was half that in the placebo group at two years of lifePrognosis • Disease more severe and persistent in young children • Periods of remission grow longer as patient ages • Mild disease at infancy: Spontaneous resolution occurs in 40% of patients after age 5 • Poor prognostic factors – Widespread AD in childhood – Associated allergic rhinitis or asthma – Family history of AD – Early age of onset4.10 Alopecia AreataGenetics • High frequency of family history, especially in patients with early onset (37%) • Twin concordance = 55% (identical twins)Immunologic Factors • Major associations: Vitiligo and thyroid disease (10%), with increased prevalence of antithyroid antibodies and thyroid microsomal antibodies in AA • Other autoimmune diseases shown to be associated: pernicious anemia, diabetes, LE, myasthenia gravis, RA, polymyalgia rheumatica, ulcerative colitisEmotional Stress • May be precipitating factor in some casesClinical Features u TIP a ATTERNS of alopecia areata: patchy (most common); • Prevalence: 0.1-0.2%, with lifetime risk of 1.7% P reticulated; ophiasis (parietal/temporal/occipital); • Affects men and women equally ophiasis inversus (sisapho – bandlike pattern in fronto • 60% present before age 20 parietotemporal scalp); diffuse • Pull test may be positive at margins, indicating early disease • Usually asymptomatic, but some patients perceive pruritus, tenderness, burning, or pain preceding hair loss • Areata – partial loss of scalp hair General Dermatology 95

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• Totalis – total loss of scalp hair • Universalis – 100% loss on scalp, eyebrows, eyelashes, and rest of body • Initial regrowth is white, followed by repigmentation • Nail dystrophy (10-66%), seen in one, some, or all nails, preceding, coinciding, or occurring after hair disease → pitting with irregular pattern or in organized rows; trachyonychia: longitudinal striations resulting in sandpaper appearance; Beau’s lines; onychorrhexis; thinning or thickening; koilonychia; red-spotted lunula; punctate or transverse leukonychiaPrognosis • Unpredictable course and pattern • Most patients see complete regrowth within one year without treatment • 10% develop severe chronic form • Predictors for poor prognosis: atopic dermatitis, childhood onset, widespread involvement, ophiasis, duration for longer than five years, onychodystrophyTreatment • All local treatments help treated areas, but do not prevent further spread • Spontaneous recovery is extremely common, with most showing regrowth within 1 year • First line: IL steroids concentration of 5 mg/cc maximum of 3 cc per visit → 0.1 cc per site, approximately 1 cm apart; after 6 months and no response, d/c • Topical steroids as monotherapy generally ineffective • Minoxidil 5%: stimulates follicular DNA synthesis and regulates hair physiology independently of blood flow influences; effective with alopecia areata involving 20-99% involvement in 25-50% of patients → initial hair regrowth in 12 weeks • Anthralin 0.25-1.0% • Squaric acid dibutyl or DNCB or DPCP (diphenylcyclopropenone) – aim is to maintain low- grade tolerable erythema, scaling, and pruritus, with weekly applications • PUVA, with either topical or systemic psoralen therapy; relapse after discontinuation occurs • Cyclosporine works, but systemic use associated with adverse effects and high recurrence rate4.11 Alopecia: Other Forms u TIPTrichotillomania a iopsy shows high B • Practice of plucking or breaking hair from the scalp or eyelashes number of catagen • Areas of alopecia characteristically contain hairs of varying length hairs, pigmentary defects and casts, • Girls under age of 10 trichomalacia, and • Treat with psychotherapy and antidepressant hemorrhageHot Comb Alopecia • African American women who straightened their hair with hot combs • Characteristically on the crown and spreads peripherally to form a large oval area of partial hair loss • Thermal damage to follicle by hot petrolatum, leading to destruction of hair follicle and follicular scar • May be same as follicular degeneration syndrome/central centrifugal scarring alopecia96 2011/2012 Dermatology In-Review l Committed to Your Future

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Pseudopelade of Brocq • Scarring alopecia where destruction of the hair follicle produces multiple round, oval, or irregularly shaped cicatricial patches of varying sizes • No pustules, crusts, or broken-off hairs are present • Onset is insidious • Female:male = 3:1 • Alopecia permanent • No inflammation with decreased or absent sebaceous glands, normal or atrophic epidermisTraction Alopecia • Prolonged tension on the hair from braiding, ponytails, rolling curlers, twisting with fingersPressure Alopecia • Occipital areas of babies lying on their backs • In adults, prolonged pressure on the scalp during general anesthesia or after prolonged bedrest • People with chronic illness after prolonged bed rest in one position • Likely related to pressure-induced ischemiaLoose Anagen Syndrome • Anagen hairs pulled from the scalp with little effort • Blonde girls • Usually improves with ageFollicular Mucinosis • Deposition of mucin in the outer root sheath and sebaceous glands • Most commonly on scalp and beard area • Secondary type associated with CTCL with widespread and chronic lesions, and patients are olderMeralgia Paresthetica • May have alopecia of the anesthetic area of the outer thighHypothyroidism • Hair coarse, dry, brittle, and sparse • Telogen hairs 3x more prevalentHyperthyroidism • Hair becomes extremely fine and sparseAlopecia Neoplastica • Hair loss from metastatic tumors • Usually breast carcinoma General Dermatology 97

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4.13 Pityriasis rubra pilaris • Small follicular papules → salmon-orange to reddish-brown color, pinhead size, and topped with scaly plug • Yellowish pink scaling patches, often begins on scalp • Solid confluent palmoplantar hyperkeratosisProgresses to: • Sides of the neck and trunk • Extensor surfaces of the extremities • Any portion of the body can be affectedClinical Features • Involvement generally symmetrical and diffuse, with characteristic small islands of normal skin within the affected areas • Palms and soles will be hyperkeratotic with fissuring • Nails: dull, rough, thickened, brittle, and striated; may crack and break; no pittingTreatment • Topical keratolytics • Systemic retinoids • Vitamin A 500,000 units daily • Systemic steroids for short term management • Methotrexate • Azathioprine • Cyclosporine4.14 Lichen sclerosus • Presents from childhood to old age, and occurs in all races • Females predominate at all agesClinical • White, polygonal, and flat-topped papules or plaques surrounded by erythematous to violaceous halo • Later, lesions coalesce into large atrophic patches, becoming smooth, slightly wrinkled, and white • Bullae may arise in patches • Pruritus can be severe, especially in anogenital area, where erosions and fissuring can occur • In women, normal anatomic structures may be obliterated • Balanitis xerotica obliterans → male involvement of the glans penis; hemorrhage is common in the glans • Extragenital lesions most frequent on the upper back, chest, and breasts, and are usually asymptomatic • + KoebnerizationCancer Risk • Increased risk of genital SCC in both men and women • Lifetime risk for women less than 5% General Dermatology 99

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Etiology • Autoimmune phenomenon, likely • 20% of both men and women have at least one autoimmune disease (vitiligo, alopecia areata, or thyroid disease), and a larger proportion have circulating antibodies • Trauma can induce lesions, and boys do better after circumcisionChildhood LS • Onset in childhood in 10-15% of cases • Girls outnumber boys 10:1 • Genital disease represents 90% of childhood LS • In girls: Symptoms include difficulty with defecation, dysuria, perineal pruritus, and perineal skin lesions • In boys: Phimosis is most common presenting sign • May resolve spontaneously, especially around puberty (50% of girls, after circumcision in boys)Treatment • Superpotent topical steroids twice daily to be tapered in either strength or frequency over time • Topical tacrolimus ointment or pimecrolimus cream, sometimes effective • Oral retinoids may work with anogenital lichen sclerosus in both men and women4.15 Granuloma annulareLocalized GA • Young adults • Lateral or dorsal surfaces of fingers, hands, elbows, feet, ankles • White, pink, flat-topped papules that spread peripherally • Never ulcerate and heal without scarring • 75% clear within 2 yearsGeneralized GA • Diabetes in 20% • Diffuse papules • May be pruritic or asymptomatic • Lasts three months to four yearsMacular GA • Flat or slightly palpable lesions over feet, ankles, and upper medial thighs • Small papules can be felt in some casesSubcutaneous GA • Most common in children • Often a history of trauma to area • Multiple lesions may be present • Generally asymptomaticPerforating GA • Dorsum of hands100 2011/2012 Dermatology In-Review l Committed to Your Future